Refer to: Public Health Service recommendations for treatment of gonorrhea '(Medical Information). West' J Med 130: 286-289, Mar 1979
Medical Information
Public Health Service Recommendations for Treatment of Gonorrhea Note: Physicians are cautioned to use no less than the recommended dosages of antibiotics.
Uncomplicated Gonococcal Infections in Men and Women Drug Regimens of Choice Aqueous procaine penicillin G (APPG) 4.8 million units injected intramuscularly at two sites, with 1 gram of probenecid by mouth. or
Tetracycline hydrochloride* 0.5 gram by mouth four times a day for five days (total dosage 10 grams). Other tetracyclines are not more effective than tetracycline hydrochloride. All tetracycdines are ineffective as a single-dose therapy. or
Ampicillin 3.5 grams, or amoxicillin 3 grams, either with 1 gram probenecid by mouth. Evidence shows that these regimens are slightly less effective than the other recommended regimens. Patients who are allergic to the penicillins or probenecid should be treated with oral tetracycline as above. Patients who cannot tolerate tetracycline may be treated with spectinomycin hydrochloride 2 grams in one intramuscular injection. *Food and some dairy products interfere with absorption. Oral forms of tetracycline should be given one hour before or two hours after meals. From the United States Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control, Atlanta, GA 30333. Submitted January 26, 1979. These recommendations were established after deliberation with the following therapy consultants: Harold C. Neu, MD, College of Physicians and Surgeons, Columbia University; Erwin H. Braff, MD, San Francisco Department of Public Health; Gary Cunningham, MD, Southwestern Medical School, Dallas; King K. Holmes, MD, PhD, USPHS Hospital, Seattle; Franklyn Judson, MD, Department of Health and Hospitals, Denver; William McCormack, MD, State Laboratory Institute, Boston; Edwin M. Mears, Jr., MD, New England Medical Center, Boston; John D. Nelson, MD, Southwestern Medical School, Dallas; Morton Nelson, MD, Orange County, California; Suzanne M. Sgroi, MD, Suffield, Conn.; Frederick Sparling, MD, School 'of Medicine, The University of North Carolina, Chapel Hill; Lt Col Edmund C. Tramont, Walter Reed Army Medical Center, Washington, DC.
286
MARCH 1979 * 130 * 3
Special Considerations * Single-dose treatment is preferred in patients who are unlikely to complete the multiple-dose tetracycline regimen. * The APPG regimen is preferred in men with anorectal infection. * Pharyngeal infection is difficult to treat; high failure rates have been reported with ampicillin and spectinomycin. * Tetracycline treatment results in fewer cases of postgonococcal urethritis in men. * Tetracyline may eliminate coexisting chlamydial infections in men and women. * Patients with incubating syphilis (seronegative, without clinical signs of syphilis) are likely to be cured by all above regimens except spectinomycin. All patients should have a serologic test for syphilis at the time of diagnosis. * Patients with gonorrhea who also have syphilis or are established contacts to syphilis should be given additional treatment appropriate to the stage of syphilis.
Treatment of Sexual Partners Men and women exposed to gonorrhea should be examined, cultured and treated at once with one of the regimens above. Follow-up Follow-up cultures should be obtained from the infected site, or sites, three to seven days after completion of treatment. Cultures should be obtained from the anal canal of all women who have been treated for gonorrhea. Treatment Failures A patient in whom therapy fails with penicillin, ampicillin, amoxicillin or tetracycline should be treated with 2 grams of spectinomycin intramuscularly. Most recurrent infections after treatment with the recommended schedules are due to reinfection and indicate a need for improved contact tracing and patient education. Since infection by penicillinase (f3-lactamase)-producing Neisseria gonorrhoeae is a cause of treatment failure, posttreatment isolates should be tested for penicillinase production. Not Recommended Although long-acting forms of penicillin (such as benzathine penicillin G) are effective in syphilo-
MEDICAL INFORMATION
therapy, they have no place in the treatment of gonorrhea. Oral penicillin preparations such as penicillin V are not recommended for the treatment of gonococcal infection.
Penicillinase-Producing Neisseria Gonorrhoeae Patients with uncomplicated pencillinase-producing Neisseria gonorrhoeae (PPNG) infections and their sexual contacts should receive spectinomycin 2 grams intramuscularly in a single injection. Because gonococci are very rarely resistant to spectinomycin and reinfection is the most common cause of treatment failure, patients with positive cultures after spectinomycin therapy should be retreated with the same dose. A PPNG isolate that is resistant to spectinomycin may be treated with cefoxitin 2 grams in a single intramuscular injection, with probenecid 1 gram by mouth.
Treatment in Pregnancy All pregnant women should have endocervical cultures for gonococci as an integral part of the prenatal care at the time of the first visit. A second culture late in the third trimester should be obtained from women at high risk for gonococcal infection. Drug regimens of choice are APPG, ampicillin or amoxicillin, each with probenecid as described above. Women who are allergic to penicillin or probenecid should be treated with spectinomycin. Refer to the sections on acute salpingitis and disseminated gonococcal infections for the treatment of these conditions during pregnancy. Tetracycline should not be used in pregnant women because of potential toxic effects for mother and fetus.
Acute Salpingitis (Pelvic Inflammatory Disease) There are no reliable clinical criteria on which to distinguish gonococcal from nongonococcal salpingitis. Endocervical cultures for N. gonorrhoeae are essential. Therapy should be initiated immediately. Admission to hospital should be strongly considered in the following situations: * Uncertain diagnosis, in which surgical emergencies such as appendicitis and ectopic pregnancy must be excluded. * Suspicion of pelvic abscess.
* Severely ill patients. * Pregnancy. * Inability of the patient to follow or tolerate an outpatient regimen. * Failure to respond to outpatient therapy. Antimicrobial Agents Outpatient treatment Tetracycline* 0.5 gram taken orally four times a day for ten days. This regimen should not be used for pregnant patients. or
APPG 4.8 million units intramuscularly, ampicillin 3.5 grams or amoxicillin 3 grams each with probenecid 1 gram. Either regimen is followed by ampicillin 0.5 gram or amoxicillin 0.5 gram orally four times a day for ten days. Patients in hospital Aqueous crystalline penicillin G 20 million units given intravenously each day until improvement occurs, followed by ampicillin 0.5 gram orally four times a day to complete ten days of therapy. or
Tetracycline* 0.25 gram given intravenously four times a day until improvement occurs, followed by 0.5 gram orally four times a day to complete ten days of therapy. This regimen should not be used for pregnant women. The dosage may have to be adjusted if renal function is depressed. Since optimal therapy for patients in hospital has not been established, other antibiotics in addition to penicillin are frequently used.
Special Considerations * Failure of the patient to improve on the recommended regimens does not indicate the need for stepwise additional antibiotics but requires clinical reassessment. * Intrauterine devices are risk factors for the development of pelvic inflammatory disease. The effect of removing an intrauterine device on the response of acute salpingitis to antimicrobial therapy and on the risk of recurrent salpingitis is unknown. * Adequate treatment of women with acute salpingitis must include examination and appropriate treatment of their sex partners because of *Food and some dairy products interfere with absorption. Oral forms of tetracycline should be given one hour before or two hours after meals. THE WESTERN JOURNAL OF MEDICINE
287
MEDICAL INFORMATION
the high prevalence of nonsymptomatic urethral infection. Failure to treat sex partners is a major cause of recurrent gonococcal salpingitis. * Follow-up of patients with acute salpingitis is essential during and after treatment. In all patients repeat cultures should be done for N. gonorrhoeae after treatment.
Acute Epididymitis Acute epididymitis can be caused by N. gonorrhoeae, Chlamydia or other organisms. If gonococci are shown by Gram stain or culture of urethral secretions, treatment should be as follows: APPG 4.8 million units, ampicillin 3.5 grams or amoxicillin 3 grams, each with probenecid 1 gram. Either regimen is followed by ampicillin 0.5 gram or amoxicillin 0.5 gram orally four times a day for ten days. or
Tetracyline* 0.5 gram orally four times a day for ten days. If gonococci are not shown to be present, the above tetracycline regimen should be used.
Disseminated Gonococcal Infection Arthritis-Dermatitis Syndrome Equally effective treatment schedules in the arthritis-dermatitis syndrome include the following: Ampicillin 3.5 grams or amoxicillin 3 grams orally, each with probenecid 1 gram, followed by ampicillin 0.5 gram or amoxicillin 0.5 gram four times a day orally for seven days. or
Tetracycline* 0.5 gram orally four times a day for seven days. Tetracycline should not be used for complicated gonococcal infection in pregnant women. or
Spectinomycin 2 grams intramuscularly twice a day for three days (treatment of choice for disseminated infections caused by PPNG). or
Erythromycin 0.5 gram orally four times a day for seven days. or
Aqueous crystalline penicillin G 10 million units intravenously per day until improvement occurs, followed by ampicillin 0.5 gram four *Food and some dairy products interfere with absorption. Oral forms of tetracycline should be given one hour before or two hours after meals.
288
MARCH 1979 * 130 * 3
times a day to complete seven days of antibiotic treatment.
Special Considerations * Admission to hospital is indicated for patients who may be unreliable, have uncertain diagnosis, or have purulent joint effusions or other complications. * Open drainage of joints other than the hip is not indicated. * Intraarticular injection of antibiotics is unnecessary.
Gonococcal Meningitis and Endocarditis Meningitis and endocarditis caused by the gonococcus require high-dose intravenous penicillin therapy. In penicillin-allergic patients with endocarditis, desensitization and administration of penicillin is indicated; chloramphenicol may be used in penicillin-allergic patients with meningitis.
Gonococcal Infections in Pediatric Patients With gonococcal infections in children beyond the newborn period the possibility of sexual abuse must be considered. Genital, anal and pharyngeal cultures should be obtained from all patients before antibiotic treatment. Appropriate cultures should be obtained from persons who have had contact with the child.
Prevention of Gonococcal Ophthalmia When required by state legislation or indicated by local epidemiologic considerations, effective and acceptable regimens for prophylaxis of neonatal gonococcal ophthalmia include the following:
Ophthalmic ointment or drops containing tetracycline or erythromycin. or
One percent silver nitrate solution.
Special Considerations * Bacitracin is not recommended. * The value of irrigation after application of silver nitrate is unknown.
Management of Infants Born to Mothers With Gonococcal Infection Infants born to mothers with gonorrhea are at high risk of infection and require treatment with a single intravenous or intramuscular injection of aqueous crystalline penicillin G 50,000 units to full-term infants or 20,000 units to low-birth-
MEDICAL INFORMATION
weight infants. Topical prophylaxis for neonatal ophthalmia is not adequate treatment. Clinical illness requires additional treatment. Neonatal Disease Gonococcal Ophthalmia Patients should be admitted to hospital and isolated for 24 hours after initiation of treatment. Untreated gonococcal ophthalmia is highly contagious. Aqueous crystalline penicillin G 50,000 units per kg of body weight per day in two doses intravenously should be administered for seven days. Saline irrigation of the eyes should be done as needed. Topical antibiotic preparations alone are not sufficient or required when appropriate systemic antibiotic therapy is given. Complicated Infection Patients with arthritis and septicemia should be admitted to hospital and treated with aqueous crystalline penicillin G 75,000 to 100,000 units per kg of body weight per day intravenously in two or three divided doses for seven days. Meningitis should be treated with aqueous crystalline penicillin G 100,000 units per kg of body weight per day, divided into three or four intravenous doses, and continued for at least ten days.
Childhood Disease Children who weigh 45 kg (100 pounds) or more should receive adult regimens. Children who weigh less than 45 kg should be treated as follows: Uncomplicated Disease Uncomplicated vulvovaginitis, urethritis, proctitis or pharyngitis can be treated at one visit with: Amoxicillin 50 mg per kg of body weight orally with probenecid 25 mg per kg (maximum 1 gram). or
Aqueous procaine penicillin G 100,000 units
per kg intramuscularly plus probenecid 25 mg per kg (maximum 1 gram).
Special Considerations * Topical or systemic estrogen therapy (or both) is of no benefit in vulvovaginitis. * Long-acting penicillins, such as benzathine penicillin G, are not effective. * All patients should have follow-up cultures and the source of infection should be identified, examined and treated.
Gonococcal Ophthalmia Ophthalmia in children is treated as in neonates but the dose of penicillin is increased to 100,000 units per kg of body weight per day, given intravenously.
Complicated Infections Patients with peritonitis or arthritis require admission to hospital and treatment with aqueous crystalline penicillin G, 100,000 units per kg of body weight per day intravenously for seven days. Aqueous crystalline penicillin G 250,000 units per kg per day given intravenously in six divided doses for at least ten days is recommended for meningitis.
Allergy to Penicillins Children who are allergic to penicillins should be treated with spectinomycin 40 mg per kg of body weight, given intramuscularly. Children older than 8 years may be treated with tetracycline 40 mg per kg per day given orally in four divided doses for five days. For treatment of complicated disease, the alternative regimens recommended for adults may be used in appropriate pediatric dosages.
THE WESTERN JOURNAL OF MEDICINE
289
Medical Information
Public Health Service Recommendations for Treatment of Gonorrhea Note: Physicians are cautioned to use no less than the recommended dosages of antibiotics.
Uncomplicated Gonococcal Infections in Men and Women Drug Regimens of Choice Aqueous procaine penicillin G (APPG) 4.8 million units injected intramuscularly at two sites, with 1 gram of probenecid by mouth. or
Tetracycline hydrochloride* 0.5 gram by mouth four times a day for five days (total dosage 10 grams). Other tetracyclines are not more effective than tetracycline hydrochloride. All tetracycdines are ineffective as a single-dose therapy. or
Ampicillin 3.5 grams, or amoxicillin 3 grams, either with 1 gram probenecid by mouth. Evidence shows that these regimens are slightly less effective than the other recommended regimens. Patients who are allergic to the penicillins or probenecid should be treated with oral tetracycline as above. Patients who cannot tolerate tetracycline may be treated with spectinomycin hydrochloride 2 grams in one intramuscular injection. *Food and some dairy products interfere with absorption. Oral forms of tetracycline should be given one hour before or two hours after meals. From the United States Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control, Atlanta, GA 30333. Submitted January 26, 1979. These recommendations were established after deliberation with the following therapy consultants: Harold C. Neu, MD, College of Physicians and Surgeons, Columbia University; Erwin H. Braff, MD, San Francisco Department of Public Health; Gary Cunningham, MD, Southwestern Medical School, Dallas; King K. Holmes, MD, PhD, USPHS Hospital, Seattle; Franklyn Judson, MD, Department of Health and Hospitals, Denver; William McCormack, MD, State Laboratory Institute, Boston; Edwin M. Mears, Jr., MD, New England Medical Center, Boston; John D. Nelson, MD, Southwestern Medical School, Dallas; Morton Nelson, MD, Orange County, California; Suzanne M. Sgroi, MD, Suffield, Conn.; Frederick Sparling, MD, School 'of Medicine, The University of North Carolina, Chapel Hill; Lt Col Edmund C. Tramont, Walter Reed Army Medical Center, Washington, DC.
286
MARCH 1979 * 130 * 3
Special Considerations * Single-dose treatment is preferred in patients who are unlikely to complete the multiple-dose tetracycline regimen. * The APPG regimen is preferred in men with anorectal infection. * Pharyngeal infection is difficult to treat; high failure rates have been reported with ampicillin and spectinomycin. * Tetracycline treatment results in fewer cases of postgonococcal urethritis in men. * Tetracyline may eliminate coexisting chlamydial infections in men and women. * Patients with incubating syphilis (seronegative, without clinical signs of syphilis) are likely to be cured by all above regimens except spectinomycin. All patients should have a serologic test for syphilis at the time of diagnosis. * Patients with gonorrhea who also have syphilis or are established contacts to syphilis should be given additional treatment appropriate to the stage of syphilis.
Treatment of Sexual Partners Men and women exposed to gonorrhea should be examined, cultured and treated at once with one of the regimens above. Follow-up Follow-up cultures should be obtained from the infected site, or sites, three to seven days after completion of treatment. Cultures should be obtained from the anal canal of all women who have been treated for gonorrhea. Treatment Failures A patient in whom therapy fails with penicillin, ampicillin, amoxicillin or tetracycline should be treated with 2 grams of spectinomycin intramuscularly. Most recurrent infections after treatment with the recommended schedules are due to reinfection and indicate a need for improved contact tracing and patient education. Since infection by penicillinase (f3-lactamase)-producing Neisseria gonorrhoeae is a cause of treatment failure, posttreatment isolates should be tested for penicillinase production. Not Recommended Although long-acting forms of penicillin (such as benzathine penicillin G) are effective in syphilo-
MEDICAL INFORMATION
therapy, they have no place in the treatment of gonorrhea. Oral penicillin preparations such as penicillin V are not recommended for the treatment of gonococcal infection.
Penicillinase-Producing Neisseria Gonorrhoeae Patients with uncomplicated pencillinase-producing Neisseria gonorrhoeae (PPNG) infections and their sexual contacts should receive spectinomycin 2 grams intramuscularly in a single injection. Because gonococci are very rarely resistant to spectinomycin and reinfection is the most common cause of treatment failure, patients with positive cultures after spectinomycin therapy should be retreated with the same dose. A PPNG isolate that is resistant to spectinomycin may be treated with cefoxitin 2 grams in a single intramuscular injection, with probenecid 1 gram by mouth.
Treatment in Pregnancy All pregnant women should have endocervical cultures for gonococci as an integral part of the prenatal care at the time of the first visit. A second culture late in the third trimester should be obtained from women at high risk for gonococcal infection. Drug regimens of choice are APPG, ampicillin or amoxicillin, each with probenecid as described above. Women who are allergic to penicillin or probenecid should be treated with spectinomycin. Refer to the sections on acute salpingitis and disseminated gonococcal infections for the treatment of these conditions during pregnancy. Tetracycline should not be used in pregnant women because of potential toxic effects for mother and fetus.
Acute Salpingitis (Pelvic Inflammatory Disease) There are no reliable clinical criteria on which to distinguish gonococcal from nongonococcal salpingitis. Endocervical cultures for N. gonorrhoeae are essential. Therapy should be initiated immediately. Admission to hospital should be strongly considered in the following situations: * Uncertain diagnosis, in which surgical emergencies such as appendicitis and ectopic pregnancy must be excluded. * Suspicion of pelvic abscess.
* Severely ill patients. * Pregnancy. * Inability of the patient to follow or tolerate an outpatient regimen. * Failure to respond to outpatient therapy. Antimicrobial Agents Outpatient treatment Tetracycline* 0.5 gram taken orally four times a day for ten days. This regimen should not be used for pregnant patients. or
APPG 4.8 million units intramuscularly, ampicillin 3.5 grams or amoxicillin 3 grams each with probenecid 1 gram. Either regimen is followed by ampicillin 0.5 gram or amoxicillin 0.5 gram orally four times a day for ten days. Patients in hospital Aqueous crystalline penicillin G 20 million units given intravenously each day until improvement occurs, followed by ampicillin 0.5 gram orally four times a day to complete ten days of therapy. or
Tetracycline* 0.25 gram given intravenously four times a day until improvement occurs, followed by 0.5 gram orally four times a day to complete ten days of therapy. This regimen should not be used for pregnant women. The dosage may have to be adjusted if renal function is depressed. Since optimal therapy for patients in hospital has not been established, other antibiotics in addition to penicillin are frequently used.
Special Considerations * Failure of the patient to improve on the recommended regimens does not indicate the need for stepwise additional antibiotics but requires clinical reassessment. * Intrauterine devices are risk factors for the development of pelvic inflammatory disease. The effect of removing an intrauterine device on the response of acute salpingitis to antimicrobial therapy and on the risk of recurrent salpingitis is unknown. * Adequate treatment of women with acute salpingitis must include examination and appropriate treatment of their sex partners because of *Food and some dairy products interfere with absorption. Oral forms of tetracycline should be given one hour before or two hours after meals. THE WESTERN JOURNAL OF MEDICINE
287
MEDICAL INFORMATION
the high prevalence of nonsymptomatic urethral infection. Failure to treat sex partners is a major cause of recurrent gonococcal salpingitis. * Follow-up of patients with acute salpingitis is essential during and after treatment. In all patients repeat cultures should be done for N. gonorrhoeae after treatment.
Acute Epididymitis Acute epididymitis can be caused by N. gonorrhoeae, Chlamydia or other organisms. If gonococci are shown by Gram stain or culture of urethral secretions, treatment should be as follows: APPG 4.8 million units, ampicillin 3.5 grams or amoxicillin 3 grams, each with probenecid 1 gram. Either regimen is followed by ampicillin 0.5 gram or amoxicillin 0.5 gram orally four times a day for ten days. or
Tetracyline* 0.5 gram orally four times a day for ten days. If gonococci are not shown to be present, the above tetracycline regimen should be used.
Disseminated Gonococcal Infection Arthritis-Dermatitis Syndrome Equally effective treatment schedules in the arthritis-dermatitis syndrome include the following: Ampicillin 3.5 grams or amoxicillin 3 grams orally, each with probenecid 1 gram, followed by ampicillin 0.5 gram or amoxicillin 0.5 gram four times a day orally for seven days. or
Tetracycline* 0.5 gram orally four times a day for seven days. Tetracycline should not be used for complicated gonococcal infection in pregnant women. or
Spectinomycin 2 grams intramuscularly twice a day for three days (treatment of choice for disseminated infections caused by PPNG). or
Erythromycin 0.5 gram orally four times a day for seven days. or
Aqueous crystalline penicillin G 10 million units intravenously per day until improvement occurs, followed by ampicillin 0.5 gram four *Food and some dairy products interfere with absorption. Oral forms of tetracycline should be given one hour before or two hours after meals.
288
MARCH 1979 * 130 * 3
times a day to complete seven days of antibiotic treatment.
Special Considerations * Admission to hospital is indicated for patients who may be unreliable, have uncertain diagnosis, or have purulent joint effusions or other complications. * Open drainage of joints other than the hip is not indicated. * Intraarticular injection of antibiotics is unnecessary.
Gonococcal Meningitis and Endocarditis Meningitis and endocarditis caused by the gonococcus require high-dose intravenous penicillin therapy. In penicillin-allergic patients with endocarditis, desensitization and administration of penicillin is indicated; chloramphenicol may be used in penicillin-allergic patients with meningitis.
Gonococcal Infections in Pediatric Patients With gonococcal infections in children beyond the newborn period the possibility of sexual abuse must be considered. Genital, anal and pharyngeal cultures should be obtained from all patients before antibiotic treatment. Appropriate cultures should be obtained from persons who have had contact with the child.
Prevention of Gonococcal Ophthalmia When required by state legislation or indicated by local epidemiologic considerations, effective and acceptable regimens for prophylaxis of neonatal gonococcal ophthalmia include the following:
Ophthalmic ointment or drops containing tetracycline or erythromycin. or
One percent silver nitrate solution.
Special Considerations * Bacitracin is not recommended. * The value of irrigation after application of silver nitrate is unknown.
Management of Infants Born to Mothers With Gonococcal Infection Infants born to mothers with gonorrhea are at high risk of infection and require treatment with a single intravenous or intramuscular injection of aqueous crystalline penicillin G 50,000 units to full-term infants or 20,000 units to low-birth-
MEDICAL INFORMATION
weight infants. Topical prophylaxis for neonatal ophthalmia is not adequate treatment. Clinical illness requires additional treatment. Neonatal Disease Gonococcal Ophthalmia Patients should be admitted to hospital and isolated for 24 hours after initiation of treatment. Untreated gonococcal ophthalmia is highly contagious. Aqueous crystalline penicillin G 50,000 units per kg of body weight per day in two doses intravenously should be administered for seven days. Saline irrigation of the eyes should be done as needed. Topical antibiotic preparations alone are not sufficient or required when appropriate systemic antibiotic therapy is given. Complicated Infection Patients with arthritis and septicemia should be admitted to hospital and treated with aqueous crystalline penicillin G 75,000 to 100,000 units per kg of body weight per day intravenously in two or three divided doses for seven days. Meningitis should be treated with aqueous crystalline penicillin G 100,000 units per kg of body weight per day, divided into three or four intravenous doses, and continued for at least ten days.
Childhood Disease Children who weigh 45 kg (100 pounds) or more should receive adult regimens. Children who weigh less than 45 kg should be treated as follows: Uncomplicated Disease Uncomplicated vulvovaginitis, urethritis, proctitis or pharyngitis can be treated at one visit with: Amoxicillin 50 mg per kg of body weight orally with probenecid 25 mg per kg (maximum 1 gram). or
Aqueous procaine penicillin G 100,000 units
per kg intramuscularly plus probenecid 25 mg per kg (maximum 1 gram).
Special Considerations * Topical or systemic estrogen therapy (or both) is of no benefit in vulvovaginitis. * Long-acting penicillins, such as benzathine penicillin G, are not effective. * All patients should have follow-up cultures and the source of infection should be identified, examined and treated.
Gonococcal Ophthalmia Ophthalmia in children is treated as in neonates but the dose of penicillin is increased to 100,000 units per kg of body weight per day, given intravenously.
Complicated Infections Patients with peritonitis or arthritis require admission to hospital and treatment with aqueous crystalline penicillin G, 100,000 units per kg of body weight per day intravenously for seven days. Aqueous crystalline penicillin G 250,000 units per kg per day given intravenously in six divided doses for at least ten days is recommended for meningitis.
Allergy to Penicillins Children who are allergic to penicillins should be treated with spectinomycin 40 mg per kg of body weight, given intramuscularly. Children older than 8 years may be treated with tetracycline 40 mg per kg per day given orally in four divided doses for five days. For treatment of complicated disease, the alternative regimens recommended for adults may be used in appropriate pediatric dosages.
THE WESTERN JOURNAL OF MEDICINE
289
